The scenario is that both of these codes were documented in the past on a patient. 438.9 Unspecified late effects of CVA AND 342.11 Spastic hemiplegia affecting dominant side The physician was queried on which code was appropriate. The documentation returned listing both codes. If we look in the ICD-9 book, we will see the following, please notice the NOTE and EXCLUDES boxes: The ICD-9 guidelines state the 342.11 excludes 438.20 - 438.22 (they can't be used together). On a future appointment, query the physician for clarification on the patient's paralysis. This is regarding hierarchical condition categories or HCC codes.
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In the ICD- 9 and ICD-10 books we have guidelines to support our coding choices. If there is ever a time to be sure the guideline is followed, this would be it. If a patient has a late effect from a previous CVA, it must be coded as such. A good example is 438.21 Hemiplegia affecting dominant side versus 342.11 Spastic hemiplegia affecting dominant side . Code 438.21 is a direct coordination with the patient's previous CVA. Choosing 342.11 would be appropriate in a patient who has this condition related to an acute or chronic illness. We thank physicians for choosing codes that are most descriptive of the diagnosis and its relationship to comorbidities
New ICD-10 Compliance Date: October 1, 2015 About ICD-10 The transition to ICD-10 is required for everyone covered by the Health Insurance Portability Accountability Act (HIPAA) . Please note, the change to ICD-10 does not affect CPT coding for outpatient procedures and physician services. Road to 10: CMS Online Tool for Small Practices Road to 10 , an online resource built with the help of providers in small practices, is now available. This tool is designed to help small medical practices jumpstart their ICD-10 transition. “Road to 10” includes specialty references and helps providers build ICD-10 action plans tailored for their practice needs. CMS Resources Access three new Medscape Education resources that provide guidance around the transition to ICD-10. Continuing medical education (CME) and nursing continuing education (CE) credits are available to health care professionals who complete the learning modules, but anyone can take them and earn a certificate of
Pancreas ICD-9 557.0 Acute Pancreatitis In ICD-10 the options include: B25.2 ….. Cytomegaloviral pancreatitis Excludes 1 congenital cytomegalovirus infection (P35.1) cytomegaloviral mononucleosis (B27.1-) K85.0 ….. Idiopathic acute pancreatitis K85.1 ….. Biliary acute pancreatitis K85.2 ….. Alcohol induced acute pancreatitis K85.3 ….. Drug induced acute pancreatitis K85.8 ….. Other acute pancreatitis K85.9 …. Acute pancreatitis, unspecified
Making the best use of electronic medical records has always been a challenge and the federal government has been scrutinizing charting on many levels. The points of interest to the auditors are: Cloning a chart note to the next date of service Problem lists being used as the billing diagnosis codes, versus only billing codes that represent the evaluation and management of the condition(s) that were considered at the time of the treatment plan Incomplete comments that may not be adequate for auditing purposes: Examples of incomplete comments, but not limited to : Stable Improving Deteriorating No change since last seen Compliant with treatment plan Labs/radiology reviewed Above / or / As above Instead comments that speak to an auditor : Stable on meds Improving since last visit May 15, 2014 No change since last seen June 3,
Acute and chronic respiratory failure ICD-9 518.84 Acute and chronic respiratory failure The options in ICD-10 include: J96.20 ….. Acute and chronic respiratory failure, unspecified whether with hypoxia or hypercapnia J96.21 ….. Acute and chronic respiratory failure with hypoxia J96.22 ….. Acute and chronic respiratory failure with hypercapnia
ICD-9-CM Diagnosis Code 436 Acute, but ill-defined, cerebrovascular disease Apoplexy, apoplectic: Apoplexy, apoplectic: NOS seizure Attack Cerebral seizure Cerebral Once the acute stage is passed, you can code any late or residual effects from the original occurrence. Reference: ICD-9-CM codes are used in medical billing and coding to describe diseases, injuries, symptoms and conditions.
Malignant Neoplasm Guideline When the primary malignancy has been previously excised or eradicated from its site and there is no adjunct treatment directed at that site and no evidence of any remaining malignancy at the primary site, use the appropriate code from category V10, Personal history of malignant neoplasm, to indicate the former site of the primary malignancy. Documentation of the extension, invasion, or metastasis to another site is coded as a secondary malignant neoplasm to that site. The metastatic site may be sequenced as the principal diagnosis if treatment is directed toward the metastatic site. Assign a code for the malignancy if a patient is receiving treatment (eg, chemotherapy, Rx, radiation therapy) for a malignancy that has already been excised. Do not assign a code from category V10, Personal history of malignant neoplasm, because the patient would not still be under treatment if the malignancy were actually a history of malignancy. It may be po
Codebusters offers a FREE, yes FREE, ICD-10-CM & PCS Training Course at Training Course It is a "ICD-10 Training Online Course by Linda Kobayashi, RHIT, CCS: The focus is on Inpatient coding, covering diagnosis and procedure codes extensively. Conditions and complications from all 22 chapters of ICD-10-CM and associated procedures are rigorously covered through life-like coding scenarios. The full course is broken up into two sections, the first covering ICD-10-CM Chapters 1-9 and the second covering Chapters 10-19 (External cause codes are present as secondary diagnoses throughout the course)." PCS is used for inpatient procedures (in the hospital). Check out their Course Flyer
Type 2 diabetes mellitus Use additional code to identify: Insulin Use (Z79.4) ICD-9 250.52 Diabetes with ophthalmic manifestations type 2 uncontrolled ICD-10 E11.3 Type 1 diabetes mellitus with ophthalmic complications E11.311 …Type 2 dm with unspecified diabetic retinopathy with macular edema E11.319 ... Type 2 dm with unspec diabetic retinopathy without macular edema E11.36 …Type 2 dm with diabetic cataract E11.39 ... Type 2 diabetes mellitus with other diabetic ophthalmic complication E11.65 … Type 2 diabetes mellitus with hyperglycemia Guidelines state: “The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.” “They should be sequenced based on the reasons for a particular encounter.” “The age of a patient is not the sole determining factor, though most type 1 diabetics develop the condition before reaching puberty.
Type 1 diabetes mellitus Use additional code to identify: Insulin Use (Z79.4) ICD-9 250.53 Diabetes with ophthalmic manifestations type 1 (juv type) uncontrolled ICD-10 E10.3 Type 1 diabetes mellitus with ophthalmic complications E10.311 …Type 1 dm with unspecified diabetic retinopathy with macular edema E10.319 ... Type 1 dm with unspec diabetic retinopathy without macular edema E10.36 …Type 1 dm with diabetic cataract E10.39 ... Type 1 diabetes mellitus with other diabetic ophthalmic complication E10.65 … Type 1 diabetes mellitus with hyperglycemia Guidelines state: “The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.” “They should be sequenced based on the reasons for a particular encounter.” “The age of a patient is not the sole determining factor, though most type 1 diabetics develop the condition before reach
These are general education comment to assist physicians in recording compliant chart notes on patients. The Chief Complaint: This should be a concise statement from the patient that describes the reason for today's encounter. The History of Present Illness (HPI) : This consists of a description of the patient's present complaint(s)……..try to include location….quality…..severity…..duration…….timing……context…..modifying factors………..associated signs and symptoms. The Review of Systems (ROS): This is an inventory of (any/all) body systems, it is obtained by asking the patient a series of questions in order to identify signs and/or symptoms that the patient may be experiencing or has experienced. The Past/Family/ and/or Social History (PFSH): Past = illnesses, surgeries, injuries and treatments Family = a review of medical events, diseases and hereditary conditions that may place the patient at risk AND Social = includes age appropriate review of past
http://www.cms.gov/eHealth/ resources.html scroll down near the bottom of the above mentioned webpage to find this section. CMS eHealth Provider Webinar Series CMS is holding a series of eHealth webinars to educate the health care community about the eHealth programs and resources available. Representatives from each of the eHealth initiatives will present on their program and then offer a Q&A session to participants. The webinars are held bi-weekly from noon to 1:30 pm ET. Past Webinars Past webinar resources are available and can be viewed by clicking on the links below: ICD-10 Resources: Get on the Road to 10 (August 5, 2014) PDF Presentation Webinar Recording (Recording ID: DWGQ5G; Key: eHealth) Administrative Simplification Overview (July 22, 2014) PDF Presentation Webinar Recording (Recording ID: 85WW8M; Key: eHealth) Million Hearts Overview (July 10, 2014) PDF Presentation Webinar Recording (Recording ID: FKS28F; Key: eHealth) Stage 2 Exchange Re
Stroke and Transient ischemic attack (TIA) To code an acute stroke, use 434.01, 434.11 or 434.91 (these are used at the time of the initial hospital admission or on initial diagnosis in a skilled nursing facility). When the provider documents “Stroke” it is coded as 434.91; “TIA” is coded as 435.9 Past stroke or TIA with no residual deficits could appropriately be documented as “history of stroke” or “history of TIA” and code V12.54. Past stroke or TIA with residual deficits would have two codes – one for history or and one for the late effects. Watch for the following: Code 434.1 Occlusion of cerebral arteries with cerebral infarction should only be assigned for acute stroke, ie, first admission to hospital or the initial diagnosis at a skilled nursing facility. Code 436 is used for apoplexy and cerebral seizures but not used to report acute stroke. [Definition of apoplexy is: A sudden loss of consciousness followed by paralysis, due to cerebral hemorrhag
Chapter 8: Diseases of Ear and Mastoid Process (H6Ø-H95) Some general notes and definitions for this chapter. IF there is a note at the beginning of the chapter that states to use an external cause code following the code for the condition of the ear, that will identify the cause of the ear condition. The external ear consists of the pinna or auricular, and the external acoustic meatus. Otitis media is any inflammation of the middle ear not indicating etiology or pathogenesis. Definitions: Otitis media (OM), acute OM (AOM), OM with effusion (OME) and lacks signs and symptoms of infection. Chronic suppurative OM is a chronic inflammation of the middle ear lasting at least 6 weeks, associated with otorrhea through a perforated tympanic membrane (TM), and indwelling tympanostomy tube, or a surigal myringotomy. Further labeled as acute - acute onset, persistent – if there is a relapse within one month of treatment, recurrent - if there are 3 or more incidents/e
Chapter 7: Diseases of Eye and Adnexa (HØØ-H59) Glaucoma is an eye condition that develops when too much fluid pressure builds up inside the eye. The increased pressure is called intraocular pressure. It can damage the optic nerve that transmits images to the brain. It the pressure continues it can cause loss of vision and even permanent blindness. Open-angle glaucoma aka wide-angle glaucoma is the most common. The fluid in the eye does not flow property through the drain of the eye, known as the trabecular meshwork. Angle-closure glaucoma aka acute or chronic angle-closure of narrow-angle glaucoma is less common. The angle between the iris and the cornea is too narrow and can cause poor drainage. Bilateral glaucoma with same type and stage Bilateral glaucoma with same type and stage – when there is bilateral glaucoma and both eyes are documented with the same type and stage, and there is a code from bilateral glaucoma, ignore it and instead report only the code for the typ
ICD-10 Webcast for Internal Medicine and Family Practice Posted This morning, CMS posted a new webcast, aimed at primary care physicians on their http://www.roadto10.org/ website: An AHIMA-certified coder presents training focused on unique ICD-10 clinical documentation needs and hot topics for each medical specialty. The five webinars will follow the same outline and objectives catering to each medical specialty with specific examples. Physician Perspective/clinical impact of ICD-10 Documentation requirements for certain conditions Documentation changes and new concepts Use of “unspecified” in ICD-10 This webcast features Dr. Maggie Gaglione, a board certified internist and bariatrics specialist, a physician in private practice in Virginia. Per Dr. Gaglione: “Comprehensive documentation is key to identifying and assigning the best diagnosis code. By doing our part, and focusing on how we document our patients’ condition we put the foundation in place t
Mental and behavioral disorders (F1—F19) 3 rd character indicates substance used Example: F10 Alcohol related disorders F11 Opioid related disorders F12 Cannabis related disorders 4 th and 5 th characters indicate the psychopathological syndrome (manifestation of behaviors and experiences) Example: F10.22 Alcohol dependence with intoxication F10.220 Alcohol dependence with intoxication, uncomplicated F10.221 Alcohol dependence with intoxication, delirium Hierarchy of use, abuse and dependence If use and abuse are documented, code only abuse If abuse and dependence are documented, code only the dependence If use and dependence are documented, code only dependence If use, abuse and dependence are all documented, code only dependence Example: F10.1- Alcohol abuse F10.2- Alcohol dependence F10.9- Alcohol use, unspecified -Uncomplicated -With intoxication -With withdrawal -With alcohol-induced psychotic disorder -With alcohol-induc
HCC University: CMS Offers New ICD-10 Content : As part of their ongoing "Road to 10" series, CMS has posted a newly released webcast on ICD-10 documentation and coding concepts ...
Angina pectoris Use additional code to identify: Presence of hypertension (I10-I15) Chronic total occlusion of coronary artery (I25.82) Exposure to environmental tobacco smoke (Z77.22) History of tobacco use (Z87.891) Tobacco dependence (F17.1-) Tobacco use (Z72.0) Occupational exposure to environmental tobacco smoke (Z57.31) ICD-9 411.1 Intermediate Coronary Syndrome ICD-10 I25 Chronic ischemic heart disease I25.110 Atherosclerotic heart disease of native coronary artery w/unstable angina pectoris I25.700 Atherosclerosis of coronary artery bypass graft(s), unspecified, w/unstable angina pectoris I25.710 Atherosclerosis of autologous vein coronary artery bypass graft(s), unspecified, w/unstable angina pectoris I25.720 Atherosclerosis of autologous artery coronary artery bypass graft(s), w/unstable angina pectoris I25